A study of the use of free-text fields within a computer medical records system

At present, the general practitioner considers any imposed rigidity or standardisation in his record keeping as an encroachment on his clinical practice. Thus, computerised clinical records are regarded with some suspicion. This paper explores the likely requirements of a computerised records system which will leave the clinician all his freedom, but at the same time give him all the potential advantages of a structured information gathering system. This investigation formed part of a joint project between IBM and the University of Sheffield Medical School, in conjunction with two general practices in the Sheffield area. The overall objective of the project was to investigate the requirements for computers in general practice, and develop an experimental GP computer system.